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What is the Medicare Shared Savings Program Track 1+ Model?

The Medicare Shared Savings Program Track 1+ Model will offer Medicare ACOs a limited downside risk structure, but still qualify as an Advanced APM in 2018.

December 30, 2016 - As the Quality Payment Program links more Medicare payments to value-based reimbursement, a new Medicare Shared Savings Program (MSSP) track will allow eligible clinicians to qualify for additional incentive payments in the program’s Advanced Alternative Payment Model (APM) track.

CMS unveiled the MSSP Track 1+ in a broader Quality Payment Program announcement in December that also included new cardiac and orthopedic care bundled payment models. The MSSP track, however, was the only new accountable care organization (ACO) opportunity.

While the MSSP Track 1+ is similar to Tracks 2 and 3 of the program, the new iteration will notably include limited downside financial risk compared to other ACOs in the program, making the track more suitable for small practice participation.

In this article, RevCycleIntelligence.com will explore the basics of the new MSSP track and how eligible providers can participate in the ACO program.

The Medicare Shared Savings Program Track 1+ is a new Medicare ACO model test announced by CMS in December. The new MSSP track builds on the program’s first track, which is an upside-only financial risk model, by including some downside financial risk. However, the risk will be less than the program’s other two tracks.

CMS designed the new MSSP track as part of its MACRA implementation strategy. In the program’s final rule, the federal agency committed to exploring additional MSSP options for increased Advanced APM participation in 2018.

“The model would be voluntary for ACOs currently participating in Track 1 of the Shared Savings Program or ACOs seeking to participate in the Shared Savings Program for the first time,” stated the final rule. “It would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program but sufficient financial risk in order to be an Advanced APM.”

When CMS announced the MSSP Track 1+ in December, the federal agency noted that the additional Medicare ACO option would help more eligible clinicians, especially those in small practices, qualify to earn the 5 percent value-based incentive payment offered in the Advanced APM track.

Many healthcare industry groups also viewed the new MSSP track as a way to help providers gradually take on more risk, particularly since most ACO models do not include downside risk.

About 61 percent of ACO contracts are upside-risk only, indicating that many ACOs are either risk-adverse or still experimenting with risk, Leavitt Partners reported in December. Upside-only contracts, however, will not qualify for Advanced APM incentive payments.

“The vast majority of ACO participants are excluded from the Advanced Alternative Payment models, but if done correctly, Track 1+ will serve as an on ramp for providers to move toward increased risk sharing,” stated Donald W. Fisher, PhD, CAE, AMGA’s President and CEO.

How is the MSSP Track 1+ structured?

The MSSP Track 1+ will build on other ACO tracks already in the Shared Savings Program, particularly Tracks 1 and 3.

Under the new model, CMS incorporated Track 1 elements by including a maximum 50 percent shared savings rate. Therefore, Medicare ACOs are eligible to earn a shared savings payment of up to 50 percent of all savings under their cost benchmark.

Shared savings payments in the new track will also depend on Medicare ACO quality performance, as with all other MSSP tracks. MSSP participants are measured on four quality domains: patient experience, care coordination and patient safety, preventative health, and at-risk populations.

Additionally, some MSSP Track 3 elements will be included in the new program model. First, the MSSP Track 1+ will have prospective beneficiary assignment to help the ACOs understand what patient populations they are accountable for before the performance year.

Second, MSSP Track 1+ ACOs will have the option to choose symmetrical thresholds for initial shared savings and losses rates. Track 3 ACOs can elect to have the same minimum shared savings and loss rates between 0.5 and 2 percent as long as it is in 0.5 percent increments.

Medicare ACOs in the MSSP Track 1+ will face limited downside financial risk, but the model will also contain enough risk to qualify the ACOs as an Advanced APM participant as long as volume and participation requirements are met.

In terms of financial risk, CMS announced in December that the MSSP Track 1+ will have a fixed 30 percent loss sharing rate.

Although, maximum levels of downside risk will also vary depending on the Medicare ACO’s composition. ACOs that include physicians or small rural hospitals may have even lower downside financial risk levels, CMS added.

Under the two-fold financial risk approach, the maximum loss limit for ACOs that are physician-led or include small and rural hospitals will be 8 percent of an ACO’s Medicare fee-for-service revenue. Other MSSP Track 1+ ACOs will have a maximum loss limit of 4 percent of the ACO’s benchmark depending on ACO composition.

The Medicare ACOs eligible for lower sharing limits will be able to increase the revenue percentage in 2019 and 2020 following Advanced APM nominal risk requirement adjustments. However, the MSSP Track 1+ ACO’s loss sharing limit, as a revenue percentage, will not go beyond the equivalent of 4 percent of the ACO’s updated historical benchmark.

Who is eligible to participate in the MSSP Track 1+?

The new MSSP track will be available to new MSSP applicants, MSSP Track 1 ACOs that are still in their agreement period, and MSSP Track 1 ACOs renewing their agreements. Track 1 ACOs interested in applying to the new model, however, will need to meet Track 1+ model eligibility criteria.

CMS also noted that benchmarks will still apply under the new track for Track 1 ACOs that already renewed their agreements. But the federal agency will include a regional benchmark adjustment consistent with the regional adjustment timeline in the MSSP final ruling from June.

Additionally, the MSSP Track 1+ application process will follow the annual MSSP application cycle. However, interested Medicare ACOs should anticipate submitting a required Notice of Intent to Apply sometime in May 2017.

Medicare ACOs will also have more opportunities to participate in the new MSSP track as part of the 2019 and 2020 MSSP application cycles.

As the 2018 MSSP application cycle approaches, CMS plans to release more information on the MSSP Track 1+ model.